Provider Demographics
NPI:1891003448
Name:BRADIGAN, JEROME W (COTA/L)
Entity Type:Individual
Prefix:MR
First Name:JEROME
Middle Name:W
Last Name:BRADIGAN
Suffix:
Gender:M
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 HOLMES PL
Mailing Address - Street 2:
Mailing Address - City:FREDONIA
Mailing Address - State:NY
Mailing Address - Zip Code:14063-1214
Mailing Address - Country:US
Mailing Address - Phone:716-672-7723
Mailing Address - Fax:
Practice Address - Street 1:425 E MAIN ST
Practice Address - Street 2:
Practice Address - City:FREDONIA
Practice Address - State:NY
Practice Address - Zip Code:14063-1451
Practice Address - Country:US
Practice Address - Phone:716-679-1581
Practice Address - Fax:716-679-9043
Is Sole Proprietor?:No
Enumeration Date:2010-09-16
Last Update Date:2010-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY005572-1224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant